Alcohol

 Alcohol ─A Double Edged Razor-Sharp Sword 

  • The moderate consumption of alcohol has been consistently associated with a reduced risk of CVD (cardiovascular disease), particularly coronary artery disease (CAD). An extensive body of scientific data shows concordant J-shaped associations between alcohol intake and a variety of adverse health outcomes, including heart disease, heart failure, diabetes, hypertension, stroke, sudden death, dementia, Raynaud’s phenomenon, and all-cause mortality.
  • It is worth highlighting the cardiovascular benefit is more than offset by non-cardiovascular death in people who consume large quantities of alcohol as shown in Figure 103.1
  • The benefit of moderate consumption of alcohol is observed in people with and without known CVD. 2 Light to moderate alcohol consumption (5 to 25 g/day) was significantly associated with a lower incidence of cardiovascular and all-cause mortality in people with heart disease.3
  • The ethanol itself, rather than specific components of various alcoholic beverages, appears to be the major factor in conferring health benefits. The health benefit is similar for beer, wine, whiskey, brandy, vodka, rum and other spirits in equivalent amounts.

 Alcohol and Heart Disease

  • Moderate alcohol consumption is known to be protective against CAD.4 Among US adults, light and moderate alcohol consumption were inversely associated with CVD mortality, even when compared with lifetime abstainers, but consumption above recommended limits was not.5  The researchers recently reported the association of alcohol consumption and cardiovascular mortality after analysis of alcohol data from 245,207 participants in nine National Health Interview Samples from 1987 to 2002. 5
  • Those consuming less than 3 drinks/wk were classified as light drinkers whereas women with 3-7 drinks/wk and men with 3-14 drinks/wk classified as moderate drinkers. Light drinkers had a 31% lower and moderate drinkers had a 38% lower CVD mortality compared to lifetime abstainers. The risk was consistently higher among those who consumed at least 3 drinks per day compared to those consuming 2 drinks per day.5
  • In a pooled analysis of 8 prospective studies from North America and Europe including 192,067 women and 74,919 men free of CVD, diabetes, and cancers at baseline, moderate daily alcohol intake (5 to 30 g/d) was inversely associated with the risk of CAD.6 The benefit of moderate alcohol consumption on reducing CVD risk may vary by age, since CAD incidence is low in men <40 years of age and in women <50 years of age.
  • The relative risk in men was reduced by 42% at 39 to 50 years of age, 28% at 50 to 59 years of age, and 15% at >60 years of age compared with abstainers. However, the absolute benefit was smaller in younger men (450/per million person years) compared to middle aged men (640 per million) and older adults (890 per million). The benefit seems to be less than one-tenth that of lowering cholesterol with statins or aspirin therapy.6 Moreover generic statins are now available for $4 a month whereas most alcoholic drinks cost more than $4 per drink.

Mechanism of Benefits

  • Various mechanisms have been proposed for the protective effect of modest alcohol consumption. These include the beneficial effects on endothelial function, insulin sensitivity, lipid profile, particularly an increase in HDL, thrombolytic profile, platelet aggregation, and inflammation.7 Other benefits include lowering serum fibrinogen levels and raising levels of adiponectin and Apo A-1.7
  • The increase in HDL with alcohol consumption is dose dependent ; average increase in HDL-C is 6 mg/dl among those who consume one to two alcoholic beverages per day and approximately twice this amount among those who consume five or more drinks.7 Among heavy drinkers the benefit of increasing the HDL is more than offset by increase in the blood pressure.
  • Consumption of alcohol does not have any significant effects on the blood levels of total cholesterol or LDL-C but increases triglycerides especially in those who already have non-optimal levels of triglycerides.7

How much is too much?

  • The amount of alcohol associated with the lowest mortality rates was between 10 and 30 g (1–3 units) per day for men and half these quantities for women (1 American unit is equivalent to 150 ml of wine, 250 ml of beer or 30–50 ml of spirits).
  • One drink in women and 2 drinks in men are not harmful to health in people with and without CVD but harm outweighs the benefit among those who consume 3 or more drinks/d or indulge in binge drinking.3
  • Binge drinking is defined as episodic excessive drinking. Although there is currently no world wide consensus on how many drinks constitute a “binge” in the US, the term is often taken to mean consuming five or more standard drinks (male), or four or more drinks (female), on one occasion. This is colloquially known as the “5/4 definition”.
  • An American drink is approximately 50% larger than European drink and contains 15g of ethanol compared to 10g for a European drink.3 This explains the upper limit of moderate drinking is two drinks in the US and three drinks in Europe.
  •  In India one small peg is 30 ml (equivalent to one European drink) and large peg is 60 ml which is equivalent to two European drinks. Therefor harm outweighs the benefits among those who consume two pegs of alcohol in India.

 Alcohol does not Protect Indians 

  • The landmark INTERHEART Study has revealed that alcohol consumption in South Asians was not protective against CAD in sharp contrast to other populations who benefit from it.8, 9 In fact Asian Indians who consume alcohol had a 60% higher risk of heart attack which was greater with local spirits (80%) than branded spirits (50%).8 The harm was observed in alcohol users classified as occasional as well as regular light, moderate, and heavy consumers.8
  • Another large study of 4465 subjects in India also confirmed the possible harm of alcohol consumption on coronary risk in men. Compared to lifetime abstainers, alcohol users had higher blood sugar (2 mg/dl), blood pressure (2 mm Hg) levels, and the HDL-C levels (2 mg/dl) and significantly higher tobacco use (63% vs. 21%).8
  • The alcohol users had a progressive increase in risk of heart disease: 30% for those who consumed <14 g/d;60% for those who consumed 14-28 g/d and 100% risk for those who consumed >28 g/d.8 The risk was 3-fold higher in those who used both alcohol and tobacco.8
  • Potential explanations for this alcohol paradox include an unfavorable variant of alcohol dehydrogenase which is known to have an impact on the effect of alcohol on CAD and the common practice of binge drinking as well as the concomitant use of tobacco.10, 11 Alcohol use along with tobacco use is much higher among Indians in the lower socioeconomic status, which  itself  is known to increase the risk of heart disease.12 

Alcohol and All-cause Mortality 

  • The dangers of combined use of tobacco and excessive alcohol consumption was further confirmed in a 30-year follow up study of 6000 men and 1000 women from Scotland. Smoking and drinking 15 or more units of alcohol on a weekly basis were associated with a 3-fold risk of total mortality.13
  • A meta-analysis on CVD mortality showed a J-shaped pooled curve with a significant maximal protection (average 22%) by alcohol at approximately 26 g/day.  In patients with CVD, light to moderate alcohol consumption (5 to 25 g/day) was significantly associated with a lower incidence of cardiovascular and all-cause mortality.1, 3

Dangers of too much Alcohol and Binge Drinking

 “Noah the tiller of soil, was the first to plant a vineyard. He drank of the wine and became drunk, and he covered himself within the tent” (genesis 9:20-21)

  • Although Noah was the first wine maker and first to suffer from embarrassment from inebriation, countless adults all over the world suffer not only from inebriation everyday, but also causes traffic accidents and fatalities.1 In fact, alcohol inebriation is the number one cause of traffic accidents worldwide, especially among young adults.
  • Alcohol is an important cause of global burden of disease (58 million DALY,5.0%), especially in the poorest regions of the world. It causes roughly 4% of all deaths worldwide (about half the number of deaths caused by tobacco) and 5% of the global burden of disease (about the same as that caused by tobacco). Alcohol was once the cause of more than half of all Russian deaths in females aged 15-54 years and three-fourths of males in the same age-group.14,19
  • Alcohol consumption was associated with a higher risk of heart attack among black Africans similar to Asian Indians.15 This may also be due to ancestral variation in alcohol dehydrogenase 1B isoform or other alcohol metabolizing enzymes.16
  • The benefit of alcohol is limited to those who consume small quantities regularly, but the harm out weighs the benefit among binge drinkers.9 Binge drinking, even among otherwise light drinkers, increases cardiovascular events and mortality. The net effect may be harmful until the age of 45 in men and 55 in women.17
  • The apparent benefit of lighter alcohol intake is essentially limited to cardiovascular deaths but an increased risk among ex-drinkers is primarily seen for non-cardiovascular deaths.1 
  • It is also important to note that alcohol consumption is associated with a wide range of medical and social problems, including alcohol dependence, liver disease, high blood pressure, obesity, stroke, raised triglycerides, traffic accidents, spousal abuse, suicide, fetal alcohol syndrome, breast and large bowel cancers. Some individuals are also at risk of progression to problem drinking.
  • From both the public health and clinical viewpoints, there is no merit in promoting alcohol consumption as a preventive strategy. Given these risks, the American Heart Association cautions people against increasing their alcohol intake or starting to drink if they don’t already do so.18

FAQ

Q.What is the economic cost of excessive alcohol use? 

A. A recent (2006) estimate showed that excessive drinking cost the U.S. $224 billion (72% from lost productivity, 11% from healthcare cost and 9% from criminal justice costs) . Of these 76% were attributed to binge drinking and 12%  to underage drinking.  Lost productivity was responsible for the majority of the cost ($161 billion). Health care and criminal justice costs (including driving under the influence), were the next two most costly. The estimated cost of excessive drinking was actually higher than smoking  (about $193 billion annually—$97 billion from lost productivity and about $96 billion in healthcare costs) and physical  inactivity ($150 billion).20

The  economic impact of excessive alcohol consumption in the U.S. is $1.90 per alcoholic is or approximately $746 per person, most of which is attributable to binge drinking.20

Excessive alcohol consumption is responsible for an average of 79,000 deaths and 2.3 million years of potential life lost in the U.S. each year, making it the third-leading preventable cause of death in this country.20  Approximately 551 million gallons of ethanol from 117 billion standard drinks were consumed in the U.S. in 2006. (Data available only from US)

Q. What is binge drinking and how common is it? 

A. Binge drinking is defined as consuming four or more drinks for women and five or more drinks for men on an occasion. More than 38 million U.S. adults binge-drink an average of four times a month, consuming as many as eight drinks on average, according to a new report from the Centers for Disease Control and Prevention.

Although binge drinking is more common among young adults ages 18 to 34, according to the report, those 65 and older who report binge drinking do so more often — an average of five to six times a month.

 

Sources

1. Klatsky AL. Alcohol and cardiovascular mortality: common sense and scientific truth. J Am Coll Cardiol. Mar 30 2010;55(13):1336-1338.

2. Di Castelnuovo A, Rotondo S, Iacoviello L, Donati MB, De Gaetano G. Meta-analysis of wine and beer consumption in relation to vascular risk. Circulation. 2002;105(24):2836-2844.

3. Costanzo S, Di Castelnuovo A, Donati MB, Iacoviello L, de Gaetano G. Alcohol consumption and mortality in patients with cardiovascular disease: a meta-analysis. J Am Coll Cardiol. Mar 30 2010;55(13):1339-1347.

4. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. Sep 11 2004;364(9438):937-952.

5. Mukamal  KJ, Chen CM, Rao SR, Breslow RA. Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002. J Am Coll Cardiol. Mar 30 2010;55(13):1328-1335.

6. Hvidtfeldt UA, Tolstrup JS, Jakobsen MU, et al. Alcohol intake and risk of coronary heart disease in younger, middle-aged, and older adults. Circulation. Apr 13 2010;121(14):1589-1597.

7. Brien S E, Ronksley PE, Turner BJ, Mukamal KJ, Ghali WA. Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies. BMJ. 2011;342:d636.

8. Roy A, Prabhakaran D, Jeemon P, et al. Impact of alcohol on coronary heart disease in Indian men. Atherosclerosis. Jun 2010;210(2):531-535.

9. Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. Jama. Jan 17 2007;297(3):286-294.

10. Bagnardi V, Zatonski W, Scotti L, La Vecchia C, Corrao G. Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? Evidence from a meta-analysis. J Epidemiol Community Health. Jul 2008;62(7):615-619.

11. Hart CL, Smith GD, Hole DJ, Hawthorne VM. Alcohol consumption and mortality from all causes, coronary heart disease, and stroke: results from a prospective cohort study of scottish men with 21 years of follow up. Bmj. 1999;318(7200):1725-1729.

12. Reddy K. S., Prabhakaran D, Jeemon P, et al. Educational status and cardiovascular risk profile in Indians. Proc Natl Acad Sci U S A. Oct 9 2007;104(41):16263-16268.

13. Hart C L, Davey Smith G, Gruer L, Watt GC. The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study. BMC Public Health. 2010;10:789.

14. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360(9343):1347-1360.

15. Steyn K, Sliwa K, Hawken S, et al. Risk factors associated with myocardial infarction in Africa: the INTERHEART Africa study. Circulation. Dec 6 2005;112(23):3554-3561.

16. Edenberg HJ, Xuei X, Chen HJ, et al. Association of alcohol dehydrogenase genes with alcohol dependence: a comprehensive analysis. Hum Mol Genet. May 1 2006;15(9):1539-1549.

17. Thadhani R, Camargo CA, Jr., Stampfer MJ, Curhan GC, Willett WC, Rimm EB. Prospective study of moderate alcohol consumption and risk of hypertension in young women. Arch Intern Med. 2002;162(5):569-574.

18. O’Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. Sep 11 2007;50(11):1009-1014.

19. Zaridze D, Brennan P, Boreham J, et al. Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48,557 adult deaths. Lancet. Jun 27 2009;373(9682):2201-2214.

20. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med. Nov 2011;41(5):516-524.

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